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The European Journal of Psychiatry

versión impresa ISSN 0213-6163

Eur. J. Psychiat. vol.28 no.1 Zaragoza ene./mar. 2014 



Primary prevention takes a leading role in World Mental Health Action






The World Health Organization (WHO) Comprehensive Mental Health Action Plan 2013-2020 establishes the "implementation of strategies for ... prevention in mental health" among its four objectives1. This policy decision recognizes the expanding knowledge-base2,3, and acknowledges the need to cover the still pending social debt of the mental health systems. WHO concurred with international experts who ranked the "grand challenges" in mental health care ("specific barriers that, if removed, would ... solve an important health problem"). Primary prevention was ranked ahead of the identification of biomarkers (ranked 18th) and the redesign of the health systems (ranked 20th)4.

Several domains support the bases for primary prevention action.

The absence of programs of primary prevention in the mental health system constitutes a human rights (HHRR) transgression. The Convention on the Rights of Persons with Disabilities5, highlights the interconnectedness between HHRR and primary prevention, e.g., articles 16 (prevention of abuse); 23 (respect for home and the family); 24 (education); 25 (health); and 28 (adequate standard of living and social protection). Importantly, the Convention on the Rights of the Child6 turns primary prevention into a chief HHRR issue. Almost all items of its preamble are relevant, such as: "Recognizing that the child, for the full and harmonious development of his or her personality should grow up in a family environment, in an atmosphere of happiness, love and understanding". It thus emerges that mental health, in partnership with other health and social sectors should advocate and assist families that fail to provide a nurturing and safe environment for their young. Furthermore, article 19 establishes: "State Parties shall take all appropriate and educational measures to protect the child from all forms of physical or mental violence, injury or abuse, neglect or negligent treatment, maltreatment or exploitation, including sexual abuse, while in the care of parent(s), legal guardian (s) or any other person who has the care of the child". Also, article 24/2f establishes: State Parties should "develop preventive care, guidance for parents and family planning education and services". Clearly, this Convention tells the signatory nations to develop public policies to assure the satisfaction of children's needs.

Obstacles remain on the way to answer the mental health needs of the populations. Recent epidemiological studies, e.g., the World Mental Health Survey (WMHS)7, have highlighted anew that no country is immune to mental and behavioral disorders. In addition, the WMHS found that the treatment gap (the difference between true and treated prevalence) was high, including in countries with well-developed services8. Therefore, mental health services should acknowledge that for many disorders more persons are not treated than treated included for schizophrenia9 and among vulnerable population groups, such as individuals with cancer10. With regard to the young, the gap is even higher than among adults (e.g., 11).

To compound this picture, stigma and discrimination constitute barriers that delay help-seeking or generate social exclusion12, while the problem of premature mortality among persons with severe mental disorders constitutes a "public health challenge"13. Furthermore, despite progress in psychopharmacology, the newer drugs have yet to meet early expectations. As for psychosocial interventions, they are infrequently used14. WHO, that had identified deficits in the mental health systems in most countries15-17 said: "Given the current limitations in effectiveness of treatment modalities for decreasing disability due to mental and behavioral disorders, the only sustainable method for reducing the burden caused by these disorders is prevention"2.

Important research findings, from e.g., epidemiology, child development, neurosciences, genetics, converge indicating that modifiable conditions, such as child maltreatment -selected here as an example of a specific target problem for primary prevention- are responsible for many mental disorders. The number of abused children is staggering. In the US (2010), child protective services received an estimated 3.3 million reports (43.8 per 1,000) of abused or neglected children18. Likely, the figures are a sub-estimation.

Epidemiologic studies have shown that child or adolescent abuse have significant impact on children19,20 (e.g., externalizing behaviors, disruptive behavior, conduct and academic problems in school, depressive symptoms), and on adolescents (e.g., delinquent behavior, drug use, academic maladjustment, depression). In addition, there are late effects among adults, among others: affective and anxiety disorders, suicide behavior, substance abuse disorders21-23, and even psychosis24. Also, general health effects have been identified. A recent study25 found that adjusting for confounders, significant positive relationships emerged between reports of childhood abuse and multisystem health risks [B (SE) = 0.68 (0.16); P < 0.001]. In conclusion, the effect of abuse contributes to the prevalence rates of mental and behavioral disorders.

Recall here that abuse leaves biological traces in the brain-hormonal systems, and in changes in the function and neuro-anatomy of brain locations, such as the amygdale, the hippo-campus, the corpus callosum, and the prefrontal cortex26. Importantly, the case for action in primary prevention has been gaining solid scientific foundations thanks to the genetic by environment (G by E) studies, with contributions to both risks27,28 and resilience29. Furthermore, the epigenetic changes caused by abuse may be carried over from one generation to the next, perpetuating a cycle of violence30.

In sum, while the research findings on the effect of abuse build a case of "toxic stress", also programs to reduce/eliminate abuse and its short- and long-term adverse effects have shown robust effects31,32. The Triple Parenting Program (PPT), purported to provide universal, indicative and selective prevention, has been found helpful33. Earlier, a program trial of indicative prevention among young mothers has shown positive outcome at age 15 of the offspring34. As a result of cutting-edge research, the American Academia of Pediatrics proposed a new route to bring about a change in the practice of pediatricians35,36, which may be mimicked by psychiatrists.

Lastly, the new era of mental health service delivery is auspicious for the inclusion of primary prevention programs. Psychiatric reform charts a new course for care by bringing it into the community. But to do more of the same, restricting the focus to curative care and rehabilitation, will be self-defeating, the social debt will remain outstanding and the human rights violations will continue. In contrast, the link between primary health care and mental health provides a unique opportunity to plan evidence-based programs of primary prevention that will contribute to answer the mounting mental health needs of the population. To conclude, WHO Plan of Action1 could make a difference.


Itzhak Levav* and Benedetto Saraceno**
*Department of Community Mental Health, Faculty of Social Welfare and Health Sciences,
University of Haifa, Haifa
**Calouste Gulbenkian Chair of Global Health, School of Medical Sciences,
Nova University, Lisbon



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Itzhak Levav, M.D.
Department of Community Mental Health
Faculty of Social Welfare and Health Science
University of Haifa
Haifa, Israel

Received: 18 April 2013
Revised: 10 November 2013
Accepted: 12 November 2013

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